www.beaconortho.com Dear Patient, Welcome to Beacon
Transcription
Physicians David B. Argo, M.D. John E. Bartsch, M.D. John J. Brannan, M.D. Robert R. Burger, M.D. Peter S. Cha, M.D. Haleem N. Chaudhary, M.D. Jaideep Chunduri, M.D. Mohab B. Foad, M.D. Stephen C. Hamilton, M.D. Sam B.H. Koo, M.D. Timothy E. Kremchek, M.D. Justin J. Kruer, M.D. Glen A. McClung, M.D. Adam G. Miller, M.D. Allison M. Phelps, M.D. Ian P. Rodway, M.D. Michael T. Rohmiller, M.D. Robert H. Rolf, M.D. Henry A. Stiene, M.D. Angel L. Velazquez, M.D. Administration Glen C. Prasser, Chief Executive Officer Mary Ellen Pope, Chief Financial Officer Andy Blankemeyer, Chief Operating Officer Becky Mitchell, Director of Human Resources Jayne Walker, Director of Marketing Locations Summit Woods (Corporate Headquarters) 500 E. Business Way Sharonville, OH 45241 Phone: 513.354.3700 Fax: 513.354.3705 Beacon West 6480 Harrison Avenue Cincinnati, OH 45247 Beacon East 463 Ohio Pike Cincinnati, OH 45255 Northern Kentucky 600 Rodeo Drive Erlanger, KY 41018 Batesville 1360 E. State Route 46 Batesville, IN 47006 Dear Patient, Welcome to Beacon Orthopaedics and Sports Medicine! Your appointment is confirmed for __________________________at______________ am/pm with Dr._______________________. Please complete the enclosed registration and history forms. Please bring the completed forms with you to your appointment. If you have had any x-rays taken or other testing done prior to your visit, please bring those as well. We also require a picture ID and insurance cards at the time of your appointment. If your insurance carrier requires a referral, please contact your primary care physician immediately. We need to receive the referral authorization prior to your visit. If this is a work related injury, we will require the following information: • Employer’s name, phone number, and contact person • First Report of Injury • Name and address of MCO • Claim Number • Date of Injury Please refer to the highlighted address on the left side of this letter for the location of your office visit. We look forward to serving you. David B. Argo, M.D. John E. Bartsch, M.D. John J. Brannan, M.D. Robert R. Burger, M.D. Peter S. Cha, M.D. Haleem N. Chaudhary, M.D. Jaideep Chunduri, M.D. Mohab B. Foad, M.D. Stephen C. Hamilton, M.D. Sam B. Koo, M.D. Timothy E. Kremchek, M.D. Justin J. Kruer, M.D. Glen A. McClung II, M.D. Adam G. Miller, M.D. Allison M. Phelps, M.D. Ian P. Rodway, M.D. Michael T. Rohmiller, M.D. Robert H. Rolf, M.D. Henry A. Stiene, M.D. Angel L. Velazquez, M.D. Lawrenceburg 605 Wilson Creek Road Lawrenceburg, IN 47025 Wilmington College Center for Sports Sciences 720 Elm Street Wilmington, OH 45177 www.beaconortho.com Beacon Orthopaedics and Sports Medicine Patient Information Patient Name:________________________________________ Date of Birth:______________Age:_______ Race: _________ Ethnicity:___________ Preferred Language: _______________ Email:_______________ Family Doctor:_____________________________________ Referral Source:_________________________ Reason for visit:____________________________________________________________________________ Briefly describe the onset and how it occurred:__________________________________________________ Does your pain radiate or move to other parts of your body?__________ If yes where_________________ Describe the pain (numb, sharp, shooting, aching)_______________________________________________ How long have you had these symptoms?____________________Are they all the time?________________ What makes your symptoms worse?___________________________________________________________ What helps improve your symptoms?_________________________________________________________ Have you been treated for this condition prior to this visit?_________If yes please list by whom and what type of treatment you have received:_________________________________________________________ _________________________________________________________________________________________ Show where your pain is located on above drawing . Please indicate your level of pain: ________________________________ None 0 1 2 3 4 5 6 7 8 9 10 - unbearable Please list any medications (including over the counter) that you have used for this condition:__________ _________________________________________________________________________________________ Have you had any of the following for this condition: X-rays__________ if yes when and where done___________________________________________ MRI __________ if yes when and where done___________________________________________ CT Scan________ if yes when and where done___________________________________________ EMG __________ if yes when and where done___________________________________________ Bone scan______ if yes when and where done____________________________________________ Medical History Height___________Weight___________Blood pressure___________Right/left handed________________ Have you ever had any neck or back surgery before:______ If so what type of surgery________________ When and name of surgeon:_________________________________________________________________ Have you had any other type of surgery:_______________________________________________________ Allergies and known types of reactions:________________________________________________________ Social History Are you: Married___ Single ___Divorced___ Widowed____ Do you live alone______________________ Do you have children:__________Do they live with you?___________ Highest grade level achieved in school:________________________________________________________ Do you currently smoke? ___no, never; ___no, I quit (when)_________; ___yes, (how much)__________ Do you drink alcoholic beverages:_____if yes how often_________________________________________ Do you drink caffeinated beverages:______if yes how often_______________________________________ Have you ever received treatment for drug and/or alcohol problems?_______If yes, specify where and when_____________________________________________________________________________________ Work History Occupation____________________________Employer___________________________________________ Length of employment______________Title_______________________Does your job require you to perform the following activities: Lifting pounds____; Sitting long hours_____; using a computer______; Lifting over your head_______; Bending_______; Driving a truck or forklift_______; Reaching over your head_____; Standing for long periods________. ________________________________________________ Patient signature __________________________________ Date ________________________________________________ Beacon Orthopaedic Physician’s Signature __________________________________ Date Patient Name: ______________________________________________ DOB: ________________________ Medications List Allergies ______________________________ ______________________________ ______________________________ ______________________________ Please list any medications you are currently taking Drug Name Dosage Directions Reason Taking Preferred Pharmacy:___________________________________ Date:_______________ Location/Number:________________________________________________________ Acknowledgement of Receipt of Notice of Privacy Practices I acknowledge that I have been provided with and understand this facility’s Notice of Privacy Practices (HIPAA information). This notice provides a complete description of the uses and disclosures of my health information. Patient Name: ________________________________________________________ Date of birth: ________________________________________________________ _________________________________________ *Patient or Representative Signature ____________________ Date _________________________________________ Name of Personal Representative (if applicable) ____________________ Relationship to Patient (ex: parent, power of attorney) *If the patient is a minor child or otherwise unable to sign this authorization, then obtain the signature of the authorized individual. Updated March 2012 – 45 CFR 164.520(c)(2)(ii) Designation of a Personal Representative A patient may designate a personal representative in writing. This person may be a spouse, adult child, members of the patient’s family, or close friend. They may also be any individual with power of attorney or other legally recognized authority to make medical decisions on behalf of the patient if he or she is incapacitated or otherwise unable to make decisions. As a general rule, a parent or legal guardian of a minor child will be recognized as their personal representative. A personal representative may act on behalf of the patient for the purpose of receiving information that otherwise would be given to the patient. Such information could include: appointment changes, messages regarding surgery and/or testing, physician’s responses to phone messages and medication requests. PLEASE NOTE: an answering machine cannot be used as an acceptable way of leaving information. A staff member may refuse to disclose information to a person identified as a patient’s personal representative if he/she believes such information should be given directly to the patient. Please note: This form does not grant permission to release medical records to these designated representatives. Requests for medical records must be made separately through the Medical Records department. Please allow approximately five business days to process a request for medical records. Person(s) to whom my information may be disclosed: __________________________________ _________________ ____________________________ Name Relationship Phone Number __________________________________ ________________ ____________________________ Name Relationship Phone Number __________________________________ ________________ ____________________________ Name Relationship Phone Number Patient Name: _________________________________ Date of birth:_______________________ Patient/Authority Signature: _________________________________________ Date: _________________ You may revoke or terminate this authorization at any time by submitting a written revocation to Beacon Orthopaedics & Sports Medicine, Ltd./Beacon Orthopaedics Surgery Center, LLC. Revised March 2012 - 45 CFR 164.502(g) Beacon Orthopaedics and Sports Medicine, LLC Financial/Credit Policy Effective April 2009 Patient name:_____________________________________________ Account #:__________________ Please print Beacon Orthopaedics and Sports Medicine, LLC (BOSM), believes that in the interest of good health care practices, it is best to establish a patient financial/credit policy between our patients and ourselves in order to avoid any misunderstandings. Our Account Representatives will be glad to discuss your account with you at any time and set up payment plans. Our primary responsibility is to deliver quality health care services. We wish to spend our time and energy toward that responsibility. We expect you to show us the same consideration as you do your other creditors, and to be honest and forthright regarding your financial responsibility. (PLEASE INITIAL THE FOLLOWING) ______1.) We expect that all co-pays, co-insurance and deductible be paid in full at each visit and prior to surgery, diagnostic testing and physical therapy. We accept cash, check, Debit Card, MasterCard, VISA, American Express, and Care Credit. ______ 2.) We file claims to your insurance company for your primary and secondary policies. You must bring your insurance card with you to every visit and make us aware of any changes in coverage. We also require a copy of your driver’s license to confirm identity. Please remember insurance coverage is a contract between the patient and the insurance company. When BOSM files for benefit for services performed, benefits are assigned to BOSM. BOSM will look to the patient for payment in full if insurance does not cover the services provided. If we do not participate with your insurance, you will likely have a higher out-of-pocket expense, so please be prepared to pay this amount ______ 3.) We do not file any insurance with your Automobile Insurance Company, or any other third party (business insurance company, employer, attorney, separated spouses, etc.) for purposes of obtaining payment. We will make every effort to provide you with proper documentation for you to receive reimbursement from those parties (i.e., claim form, statement or report).Please speak with our billing representative. We do not accept Letters of Guarantee or other promises to pay when cases settle. You will be extended credit only if arrangements are made in advance and only within our standard guidelines for credit. ______ 4.) If the patient is under age 18, a parent or guardian must sign below. If the minor does not reside with both parents, and there is a dispute over which parent is responsible for any remaining balances, we will ultimately rely upon the parent/guardian who brought the child to the office for financial responsibility. All minors will not be seen unless accompanied by a guardian or a signed authorization from that guardian allowing our physicians to provide medical treatment. ______ 5.) A service charge of $20.00 will be applied to returned checks. You will be asked to bring cash, money order or cashiers check to our office to cover the amount of the check plus the service charge. If you present two (2) checks that are returned to us, we will require cash for future services. ______ 6.) If your balance is not paid in a timely manner, we reserve the right to forward your account to an outside collection agency or attorney. All fees assessed by the agency or attorney will be charged to you and become part of your outstanding balance. By signing this agreement, you are acknowledging that you understand our financial/credit policy and agree to pay for all services that are received. Patient/Guardian Signature:_________________________________ Date:_______________________ Driving Directions to Beacon Orthopaedics Summit Woods Complex 500 E-Business Way Sharonville, Ohio 45241 513-354-3700 From I-75 Take I-275 East to Reed Hartman (Exit #47) Stay in middle lane on exit ramp and follow signs to Kemper Road. Turn right on Reed Hartman and immediately get into the left lane for Kemper Road Connector. Turn left at the first traffic signal. This will take you up a short hill to Kemper Road and by the Double Tree Inn. Turn right (east) on Kemper to second traffic signal, which is E-Business Way. Turn left to Beacon Orthopaedic Center at 500 E-Business Way. From I-71 Take I-275 West to Reed Hartman (Exit #47). Turn left and cross over the interstate. Once over the interstate, Reed Hartman turns into two lanes. Stay in the left lane. Turn left at first traffic signal. This will take you up a short hill to Kemper road and by the Double Tree Inn. Turn right (east) on Kemper to second traffic signal, which is E-Business Way. Turn left to Beacon Orthopaedic Center at 500 E-Business Way. Driving Directions to Beacon West 6480 Harrison Ave Cincinnati, Ohio 45247 513-354-3700 From Northern Cincinnati Travel South I-75 Take 275 West to I-74 East to the Rybolt Exit Turn left at the exit Turn right onto Harrison Ave Go up the hill and stay in the left lane You will pass Kohls and Meijers Turn left at 6480 Harrison Avenue Proceed ahead up the hill to Beacon Orthopaedics From West Harrison and Indiana Take I-74 east to Rybolt Exit Turn left at the exit Turn right onto Harrison Ave Go up the hill and stay in the left lane You will pass Kohls and Meijers Turn left at 6480 Harrison Ave Proceed ahead up the hill to Beacon Orthopaedics From Northern Kentucky Travel I-75 North to I-74 West Take Exit #11 Harrison/Rybolt Exit Turn left onto Harrison Ave You will pass Kohls and Meijers Turn left at 6480 Harrison Ave Proceed ahead up the hill to Beacon Orthopaedics From Harrison Avenue, South Take Harrison Ave North from Race Road for approximately 2+ miles Turn right at 6480 Harrison Ave Proceed ahead up the hill to Beacon Orthopaedics Directions to Beacon East 463 Ohio Pike Cincinnati, OH 45255 513-354-3700 From South of Cincinnati: I-75/I-71 North Take I-71/75 North to I-275 East Take the Beechmont Avenue exit 65 and turn left. Stay in the left hand lane. Turn left onto Hamblen Road (Bob Sumerel Tire and Olive Garden will be to the left) Parking is available on the side and front of the building From Northern Cincinnati: I-75/I-71 South Take I-71/I-75 South to I-275 East Take the Beechmont Avenue exit 65 and turn right. Stay in the left hand lane Turn left onto Hamblen Road (Bob Sumerel Tire and Olive Garden will be to left) Parking is available on the side and front of the building. Driving Directions to Beacon Orthopaedics at Wilmington College Center for Sports Sciences 720 Elm Street Wilmington, OH 45177 513-354-3700 From I-71 (Headed South) Take exit 50 and turn left on US-68 toward Wilmington Continue on US-68 6.3 miles Stay right on US-68 to N South Street Turn left onto East Main Street 0.5 miles Turn right onto College Street 0.3 miles Turn left onto Elm Street Location will be just past and behind the YMCA on your right From I-71 (Headed North) Take exit 45 for OH-73 Toward Waynesville/Wilmington Turn right onto OH-73 E 5.7 miles Use the right lane to take the US 68 ramp to Xenia/Wilmington Turn right onto US-68 S 1.5 miles Turn left onto East Main Street 0.5 miles Turn right onto College Street 0.3 miles Turn left onto Elm Street Location will be just past and behind the YMCA on your right
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